1. Tips for Policies and Procedures
Lydia Lehnertz, WI AHEC CHIP Intern - Buffalo County & Alyssa Weinrich, WI AHEC CHIP Intern – Pepin County

2. Introduction
Assigned to project from Wisconsin Area Health Education Center (AHEC) Community Health Internship Program (CHIP) within Pepin and Buffalo Counties.
Goal to update policy and procedure manual to a standardized electronic format
Created PowerPoint to help others find an effective way to update, maintain and create policies and procedures in an electronic format

3. Contents Table of Contents Guide to Hyperlinking Standardized Template
Policy Review
Revision Log
Archiving Documents
Tips for Accreditation

4. Standardized Table of Contents
Useful components of electronic table of contents:
Subheadings organized in logical way
Columns for dates effective, reviewed, and revised
Policies hyperlinked from title listed in table of contents

5. Example Table of Contents

6. Guide to Hyperlinking 2 different options:
1) You can hyperlink existing text
Ex: A hyperlink for policy xyz…
2) You can select location where you want hyperlink after text
Ex: A hyperlink for policy xyz can be found here: s://publichealth/policy/xyz

7. How to Hyperlink Existing Text
Highlight words you want to hyperlink
Right click your mouse
From dropdown select hyperlink
On left hand side select “existing file or webpage”
Select location of file
Click “ok”

8. How to Hyperlink Following Text
Place curser where you want to hyperlink
Right click your mouse
From dropdown select hyperlink
On left hand side select “existing file or webpage”
Select location of file
Click “ok”

9. How to Open a Hyperlink Right click the text you hyperlinked
Select “open hyperlink” from dropdown menu
File should open automatically in new window

10. Standardized Template for Policies and Procedures
Found many different methods for structuring policy and procedure manual
Decided to use format that included purpose statement, policy, procedure, references/legal authority
Could possibly add other components such as: responsible staff, definitions, supplies needed, related policies
Key to keep the policy and procedure as SIMPLE as possible

11. Example Policy Template

12. Policy Review
There is no set guideline as to how often policies need to be reviewed; however, they need to be kept current
Local policies at each health department give the specific details within their policies (ex: create and/or execute a policy on policy revisions)

13. Tips for Keeping Policies Current
Use a table of contents with columns for effective date, date reviewed/revised
Develop a sign-off sheet to be kept in a central location
Create a revision log which allows you to make note of future changes needed to policies
Find an effective method for keeping revisions current (ex: policy review at staff meetings, individual accountability)

14. Example Revision Log

15. Archiving Documents
Health Departments should have their own policy on policy retention
One option for organizing policies is to create “archived policies” folder within electronic policy and procedure manual
Organize based off method that works best for your health department

16. Tips for Accreditation
Policies and procedures cannot be drafts
Must be in electronic format
Must have documentation for each standard and measure within Public Health Accreditation Board Standards and Measures

17. Helpful Resources for Accreditation
National Association of City and County Health Officials (NACCHO)
- Contains toolbox with examples of each domain
Public Health Accreditation Board (PHAB)
- Contains structure and guidelines for accreditation
process
Public Health Accreditation Wisconsin (PHAW)
- Private webpage available upon request from
regional office

18. PHAB Website Found to be very helpful throughout this process
Contains standards and measures necessary for becoming accreditation
Each measure requires documentation to prove compliance
Next slide outlines measures that may require a policy and procedure

19. Policies and Procedures Necessary for Accreditation in 2012
Measure
Description
2.2.1A
Two examples of written protocols for containment/mitigation of health problems and hazard
2.3.1A
Outline how the health dept. maintains 24/7 access to support services in emergencies. May be in the All Hazards Emergency Operations Plan or separate.
2.3.2A
Policies and procedure that assure 24/7 laboratory coverage may be in the all Hazards Emergency Operations Plan or separate protocols for the handling and the submission of specimens.
2.3.3A
Identify support personnel who will be called on to provide surge capacity
5.4.2A
Written communication protocols that provides a means for the department to contact health care providers, response partners, the media, and others 24/7. Must include contact information and be updated at least annually.
6.3.1A
Written procedures for communications, updated biennially that include: 1) Disseminating accurate, timely, and appropriate information for different audiences 2) informing and/or coordinating with community partners for the communication of targeted and unified public health messages 3) Maintaining a current contact list of media and key stakeholders 4) Designating a staff position as the public information officer 5) Describing responsibilities and expectations for positions interacting with news media and the public
6.3.2A
Protocol for scheduling inspections of regulated entities

20. Policies and Procedures for Accreditation Continued
Measure
Description
6.3.5A
Must provide a communication protocol for interagency notifications. The health department must provide a protocol for notifying the public when required.
9.1.1A
Document leadership’s engagement in setting a policy for and/or establishing a performance management system for department
10.2.1A
Human subjects research protection policy. If never involved with research that involves human subjects, a policy stating that fact
11.1.1A
Must provide written operational policies in hard copy or electronic format. Reports of review at least every 5 years or proof of regular updating process. Description of methods for staff access to policies.
11.1.2A
Maintain written policies regarding confidentiality, including applicable HIPPA requirements.
11.1.3A
Policy and procedure for the development of interventions and materials that are culturally and linguistically appropriate for the population it serves in its jurisdiction.
11.1.4A
Human resource policy and procedure manual or individual policies. The policies and procedures must address the following: Personnel recruitment, selection, and appointment; equal opportunity employment; salary structure; hours of work; benefits package; performance evaluation process and individualized development plans; problem solving and complaint handling, including sexual harassment. Written description of how staff access human resources policies and procedures.

21. Conclusion Keeping policies current is easier said than done
Find a method that works best for your health department
Best of luck and remember to keep it simple!